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Biomedical subjects

D C Hohn

Publications and source records attributed to D C Hohn.

At least 37 records · Page 2Linked to original sources
PubMed1990

Chemoembolization for hepatocellular carcinoma.

Fifty-one patients with unresectable hepatocellular carcinoma (HCC) were treated with Gelfoam (absorbable gelatin sterile powder; The Upjohn Co, Kalamazoo, MI) chemoembolization. A mixture of Gelfoam powder, contrast media, and three drugs (doxorubicin, mitomycin, and cisplatin) was injected under fluoroscopic guidance via a percutaneous catheter into the hepatic artery until stagnation of blood flow was achieved. Of the 51 patients, 50 are assessable for response, and all are assessable for toxicity and complications. The median percent of liver replacement was 50% (range, 15% to 95%). By conventional response criteria, there were 12 partial responses (PRs) (24%), 13 minor responses (MRs) (26%), 12 stabilization of disease (SD) (24%), and 13 (26%) progressive disease (PD). Tumor liquefaction was noted on computed tomographic (CT) scan in 35 of 50 patients (70%). Of the 34 patients with elevated alpha-fetoprotein (AFP), 23 (68%) had a greater than 50% reduction following treatment. Responding patients were re-treated at the time of tumor progression if they still met the entry criteria. The median survival of assessable patients from the time of treatment was 207 days and from the diagnosis of the primary was 302 days. Fourteen patients remain alive at 3 months to 3 years following treatment. The vast majority of patients had transient pain, fever, nausea, and elevation in liver enzymes. Ascites developed in 14 patients. There were two treatment-related deaths: one from tumor hemorrhage and one from liver failure. Chemoembolization appears to have significant activity in patients with hepatocellular carcinoma and is relatively well tolerated.

Adolescent↗
PubMed1989

A randomized trial of continuous intravenous versus hepatic intraarterial floxuridine in patients with colorectal cancer metastatic to the liver: the Northern California Oncology Group trial.

In 1983, the Northern California Oncology Group (NCOG) instituted a randomized trial of intravenous (IV) versus intraarterial (IA) floxuridine (FUDR) administered via an implantable pump for patients with colorectal cancer metastatic to the liver. The study objectives were to compare the hepatic response rate, time to hepatic progression, and toxicity for the two treatment arms. The study design, which allowed patients failing IV FUDR to crossover to the IA arm, prevents a meaningful comparative analysis of survival. Patients with liver-only metastases (N = 143) were randomized, 76 to the IV arm and 67 to the IA arm, and 115 patients (65 IV, 50 IA) were fully evaluable. Of the 65 patients in the IV arm, 28 crossed over to IA treatment after failing IV FUDR. The dose-limiting toxicity of IV FUDR was diarrhea, whereas biliary toxicity limited both the dose and duration of IA FUDR therapy. Of the first 25 patients treated with IA FUDR at a dose of .3 mg/kg/day, 10 developed radiographically evident biliary strictures, and three developed permanent jaundice. With reduction of the initial IA FUDR dose to .2 mg/kg/day, and adoption of a policy of early dosage reduction, treatment interruption, or termination of therapy for persistent elevations in alkaline phosphatase, only two further cases of serious biliary toxicity occurred. However, 26 of the 50 IA FUDR patients ultimately had therapy terminated because of drug toxicity rather than disease progression. When compared with systemic infusion, infusion into the hepatic artery greatly enhanced the antitumor activity of FUDR against colorectal liver metastases. Although biliary toxicity is the most serious limitation of this form of therapy, biliary stricture and jaundice usually can be averted through careful monitoring of liver enzymes and early dosage reduction.

Adult↗
PubMed1988

Extravasation. A serious complication of the split-sheath introducer technique for venous access.

The use of split-sheath introducers to place venous access catheters results in the potential for subcutaneous extravasation and tissue injury or necrosis. We present six cases that demonstrate this complication and illustrate the probable mechanism. The safe use of these catheters requires verification that blood can be aspirated from the catheter and a high index of suspicion for extravasation when symptoms develop.

Adult↗
PubMed1987

Immunodeficiency-associated thrombocytopenic purpura (IDTP). Response to splenectomy.

Immunodeficiency-associated thrombocytopenic purpura (IDTP) is a feature of the acquired immunodeficiency syndrome--related complex. Current therapeutic modalities for IDTP include splenectomy and the administration of corticosteroids or other agents. Empiric treatment of IDTP has been analogous to that for immunologic thrombocytopenic purpura (ITP). The present report reviews 15 patients who underwent splenectomy for IDTP, demonstrates the successful use of surgical therapy, and defines our indications for splenectomy in the treatment of this disorder. Thirteen of 15 patients had initially failed to respond to steroid therapy. Fourteen patients (93%) initially responded to splenectomy, with platelet counts increasing to 150 X 10(9)/L (150,000/mm3) or greater. A continuing complete response was achieved in nine patients (60%) following splenectomy. After postsurgical adjunctive therapy, durable remission was achieved in 73% (11/15) of the patients. Complications occurred in three patients, and there were no deaths. The mean follow-up was 12.4 months. Splenectomy may be performed in the treatment of IDTP with acceptable morbidity and likelihood of response.

Acquired Immunodeficiency Syndrome↗
PubMed1986

Toxicities and complications of implanted pump hepatic arterial and intravenous floxuridine infusion.

Toxicities and complications were prospectively analyzed in patients with liver metastases receiving hepatic intra-arterial (IA) and systemic intravenous (IV) floxuridine (FUDR) with the Infusaid (Intermedics-Infusaid Corp., Norwood, MA) implantable pump. Among 55 patients treated with IA FUDR (0.3-0.1 mg/kg/day X 14, every 28 days), elevations in liver enzyme values, not attributable to disease progression, developed in 96% of patients. Serious biliary toxicity occurred in 31 patients (56%). In 16, biliary sclerosis was documented radiographically and was diagnosed clinically in 15 additional patients. Ten patients were hospitalized for biliary toxicity, including five who required cholecystectomy for acalculous cholecystitis. Because of the high reported incidence of serious gastroduodenal toxicity after IA FUDR infusion, our procedure for hepatic arterial cannulation was designed to eliminate misperfusion of the stomach and duodenum with drug; none of our patients experienced FUDR-associated gastroduodenal ulceration or bleeding. Cyclic IV FUDR (0.05-0.15 mg/kg/day X 14, every 28 days) was administered to 31 participants of the Northern California Oncology Group trial (3L-82-1) of IV versus IA FUDR. Dose-limiting toxicity was diarrhea. Serious toxicities were: protracted diarrhea (three), dermatitis (two), tear duct stenosis (two), and stomatitis (two). Three patients were hospitalized for toxicity. No hematologic or biliary toxicity occurred. The optimal route for treatment of hepatic metastases with continuous FUDR infusion has not yet been established. Systemic IV infusion has low morbidity, but preliminary response data need to be substantiated in controlled clinical trials before there can be widespread clinical application. High response rates for IA infusion have been previously documented. Morbidity due to acalculous cholecystitis and gastroduodenal ulceration can now be avoided. Despite significant progress in characterization of hepatobiliary toxicity, it remains dose-limiting. Continuous IA FUDR infusion should remain under the aegis of dedicated treatment centers until standardized protocols with diminished toxicity are established.

Alkaline Phosphatase↗
PubMed1986

Home support of patients with end-stage malignant bowel obstruction using hydration and venting gastrostomy.

Palliative terminal care of patients with malignant bowel obstruction is a major clinical and ethical challenge. These patients are often mentally alert and ambulatory, but are kept in the hospital for hydration, nasogastric suction, and pain control. Parenteral nutrition requires frequent metabolic monitoring, is expensive, and is ethically questionable. We have used an alternative method of home management for 27 patients who met the following criteria: inoperable bowel obstruction due to untreatable cancer, an estimated life expectancy of between 2 weeks and 3 months, and understanding of the goals and limits of therapy. Hydration was provided by 10 percent dextrose and electrolyte solutions administered as overnight infusions through long-term central venous catheters. Thirteen patients with complete bowel obstruction required a venting gastrostomy which, when connected to passive drainage, relieved nausea and vomiting. The mean duration of survival was 64 days (range 9 to 223 days). Acceptance by patients and families was excellent, although most acknowledged increased costs due to limited insurance coverage for outpatient care. Seven patients returned to the hospital for terminal care (average stay 3.2 days), and 20 chose to die at home. The mean daily expense for fluids and supplies was +73.50, with an overall cost decrease of $900,000 compared with inpatient care. Home support with fluids and gastric venting is a humane, cost-effective alternative to in-hospital care for selected patients.

Abdominal Neoplasms↗
PubMed1986

Sclerosing cholangitis associated with hepatic arterial FUDR chemotherapy: radiographic-histologic correlation.

During a 2-year period, cholangiography was performed on 17 patients with clinical evidence of cholestasis who were receiving hepatic intraarterial floxuridine (IA-FUDR) infusions for treatment of metastatic colorectal adenocarcinoma. The development of cholestasis was associated with persistently elevated alkaline phosphatase, but serial CT examinations of the liver showed no progression of the tumor. All patients had cholangiographic abnormalities (by endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, or operative cholangiography) of the biliary ductal system similar to those in idiopathic sclerosing cholangitis. Certain features, however, appear specific to IA-FUDR-induced cholestasis. All patients studied had segmental involvement at the common hepatic duct bifurcation. The cystic duct and gallbladder were often involved, but the distal common bile duct was spared. Histologic features of periportal and periductal fibrosis were present in specimens obtained from percutaneous liver biopsy in three patients, cholecystectomy in four patients, and autopsy in two patients. When clinical signs of hepatic dysfunction occur in the absence of tumor progression, biliary sclerosis must be suspected.

Cholangiography↗
PubMed1986

Total hepatic arterial perfusion after occlusion of variant lobar vessels: implications for hepatic arterial chemotherapy.

The surgical placement of hepatic arterial cannulas, followed by intra-arterial chemotherapy, is a promising technique for the treatment of unresectable hepatic malignancies. Complete perfusion of the liver with drugs is essential, but may be difficult to achieve in some patients with variant arterial anatomy. In 79 patients, we encountered 15 with variant anatomy that precluded standard single or dual cannulation techniques. In 12 patients variant lobar arteries were ligated at surgery. Postoperative transarterial coil occlusion was used in three patients. In each case, the remaining hepatic lobar artery was perfused with a single catheter. Complete bilobar hepatic perfusion was documented by a technetium 99m macroaggregated albumin scan in 13 of 15 (87%) patients. Of patients scanned more than 5 days after occlusion, six of six (100%) had full perfusion of the region supplied by the variant lobar vessels. Postocclusion hepatic arteriography demonstrated translobar collateral vessels that provided perfusion of the region of the occluded variant artery. There was no added morbidity from lobar arterial occlusion and no disparity in tumor response between perfusion by direct cannulation and perfusion by collateral flow. Occlusion of variant hepatic lobar arteries in conjunction with single catheter cannulation to infuse the remaining lobar vessels is a useful technique to provide total hepatic arterial perfusion in patients with variant hepatic arterial anatomy.

Adult↗
PubMed1985

The role of splenectomy in multimodality treatment of thrombotic thrombocytopenic purpura.

Current treatment modalities for thrombotic thrombocytopenic purpura (TTP) include plasmapheresis (PP), splenectomy, steroids, dextran, other antiplatelet agents, and vinca alkaloids. Prior to the development of PP and use of multimodality treatment for TTP, mortality rates exceeded 50%. This report reviews 11 patients treated for TTP, demonstrates the successful use of splenectomy as salvage therapy, and defines our indications for splenectomy in the treatment of this disorder. Ten of 11 patients were initially treated with PP; three responded completely and one died of fulminant disease. Six patients had a transient partial response to plasmapheresis and were subsequently treated with splenectomy, steroids, and dextran-70. Initial plasmapheresis resulted in improvement in laboratory values and clinical status in those patients requiring splenectomy. Durable remission (6-48 months) was achieved in 91% of patients with minimal morbidity.

Adult↗
PubMed1985

Avoidance of gastroduodenal toxicity in patients receiving hepatic arterial 5-fluoro-2'-deoxyuridine.

Gastroduodenal inflammation and ulceration have been frequently observed in patients receiving continuous hepatic arterial infusions of 5-fluoro-2'-deoxyuridine (FUDR) for liver malignancy. Thirty-five patients with metastatic colon cancer received hepatic arterial FUDR administered with implanted infusion pumps. At surgery, particular care was taken to identify and divide those vessels arising from the hepatic arteries distal to the point of cannulation that supplied the superior border of the distal stomach and proximal duodenum. None of the patients developed signs or symptoms of gastritis or ulcer attributable to chemotherapy. We contend that gastritis and ulcer in patients receiving hepatic arterial FUDR are due to misperfusion of drug into the upper gastrointestinal tract and that these complications can be largely avoided by use of appropriate surgical techniques.

Colonic Neoplasms↗
PubMed1984

A comparative study of skin blood flow in musculocutaneous and random pattern flaps.

The present study in dogs was performed to evaluate the development of blood flow in cranial-based, rectus abdominis musculocutaneous (MCF) and random pattern (RPF) flaps and in adjacent intact skin before and after operation. Prior to raising of the flaps the intact skin area had the same blood flow in all the test injections. Following flap elevation blood flow in the MCF increased and on the second postoperative day (POD) it was 2.6 times the preoperative value. From POD 2 through POD 15 only minor changes were found for blood flow in MCF. Blood flow in the RPF immediately after surgery was only 31% of the preoperative value and 24% of the MCF value. After POD 2-3 blood flow in RPF, however, increased and reached the preoperative level and continued to increase through POD 15. Intact adjacent skin showed changes similar to those of MCF through POD 6, however, by POD 15 blood flow had decreased and was lower than that in MCF and RPF. Blood flow rates at remote sites in the groin and shoulder were identical and showed only a slight increase during the first two postoperative days. It is concluded that MCF have an early and continuous increase in blood flow after raising, while RPF have an early decrease. RPF, however, develop a subsequent increase in flow lasting through POD 15. Intact adjacent skin also showed increased blood flow which could not be attributed to a generalized increase in skin blood flow.

Animals↗
PubMed1984

Hepatic arterial chemotherapy for colorectal cancer metastatic to the liver.

Hepatic metastases of colorectal origin are resistant to radiation and immunotherapy. Traditional intravenous chemotherapy produces responses in 10% to 30% of patients, and surgical resection is feasible in approximately 20% of patients who have a solitary or unilobar lesion. Infusion of cytotoxic agents into the hepatic artery, introduced 2 decades ago, is the most promising form of therapy for unresectable hepatic metastases. Fluorouracil, floxuridine, and mitomycin have been most commonly administered by hepatic arterial infusion. The recent development of a totally implantable pump has allowed prolonged ambulatory infusion of chemotherapeutic agents into the hepatic artery. We review the recent data on the pharmacology, therapeutic outcome, administration techniques, and complications of hepatic arterial chemotherapy. Future trials in this area should use uniform stratification variables and standardized criteria for evaluating response, time to progression, and survival.

Antineoplastic Agents↗
PubMed1983

Fine-needle aspiration of palpable breast masses. A program for staged implementation.

Fine-needle aspiration (FNA) can provide a morphologic diagnosis of palpable breast masses in an accurate, efficient, inexpensive, and safe manner. However, how one acquires the skill to perform the FNA and interpret the resulting smears, while protecting the patient from the risk of false-positive or false-negative results, is scarcely considered. We used a three-phase program to acquire experience with FNA while providing services for 205 patients over a 16-month period. We performed FNA sequentially in vitro, in vivo, and finally in vivo for clinical use. With available literature and this graduated implementation program, physicians totally inexperienced with FNA can achieve results similar to those of medical centers having experience with thousands of patients.

Biopsy, Needle↗
PubMed1983

Antibiotic prophylaxis in surgical procedures. A critical analysis of the literature.

The use of prophylactic antibiotics in surgery is widespread and often inappropriate. The lack of well-designed clinical studies partially explains the present confusion regarding the subject. We reviewed the literature in English on antibiotic prophylaxis through June 1982. Antibiotic prophylaxis reduces the incidence of wound infection after colorectal surgery, vaginal hysterectomy, and laryngeal and oropharyngeal resection for carcinoma, and in high-risk patients undergoing gastroduodenal or biliary surgery. In clean operations such as cardiac surgery, vascular procedures, and orthopedic surgery with placement of prostheses, the high morbidity associated with an infection justifies the use of antibiotics even though the risk of infection is small. There are conflicting data on the usefulness of prophylaxis in abdominal hysterectomy, cesarean section, noncardiac thoracic procedures, and urologic surgery. The effectiveness of prophylaxis in neurosurgery cannot be evaluated at the present time.

Administration, Oral↗
PubMed1983

Activation of chemotactic factors in serum and wound fluid by dextranomer.

Dextranomer (Debrisan), a frequently used wound-cleansing agent, was shown to cause activation of chemotactic factors in human serum and wound fluid. These factors attracted both polymorphonuclear leukocytes (PMNs) and mononuclear leukocytes (MNs) in an agarose migration assay. When Debrisan-activated sera were used as the chemotactic stimulus, migration scores for PMNs and MNs were respectively 50% and 70% of the values obtained with zymosan-activated sera. Differential chelation studies demonstrated that Debrisan causes activation of the alternate complement pathway, and the factors produced cause receptor-mediated leukotaxis of both PMNs and MNs. Formation of chemotactic factors at the wound surface is a mechanism whereby Debrisan could conceivably augment wound healing and the inflammatory response to infection.

Chemotactic Factors↗
PubMed1980

Production of acute pulmonary injury by leukocytes and activated complement.

The adult respiratory distress syndrome (ARDS) frequently occurs after sepsis and major trauma. Since both sepsis and trauma may cause activation of the complement system, we have infused rabbits with complement-activated plasma (AP) and have studied the effects on leukocyte counts, respiratory rate, PaO2, and lung morphology. Sustained AP infusion caused: (1) early granulocytopenia, (2) progressive hypoxemia and tachypnea, and (3) pulmonary vascular plugging by aggregates of degenerating granulocytes with interstital edema and endothelial injury. These changes were not observed in control animals infused with unactivated plasma or in animals rendered leukopenic with nitrogen mustard. Complement activation in patients with sepsis and trauma may be an etiologic factor in the development of ARDS.

Agranulocytosis↗
PubMed1977

Antimicrobial systems of the surgical wound. I. A comparison of oxidative metabolism and microbicidal capacity of phagocytes from wounds and from peripheral blood.

Oxygen consumption glucose oxidation via the hexose monophosphate shunt, and superoxide production by resting and stimulated leukocytes derived from rabbit blood and from experimental rabbit wounds five to seventeen days old were measured and compared. In vitro killing of staphylococci by blood and wound leukocytes was also measured. In all of these studies there were no significant functional differences between blood and wound cells. The data presented suggest that under the same in vitro conditions, blood and wound leukocytes are functionally equivalent, that tissue mobilization does not cause alteration of wound leukocytes, and that aging of the wound does not impair the microbicidal capacity of wound leukocytes.

Animals↗